CDA On FHIR England - End of Life Care Document

COFE-SPMH-Observation-1

Details of the patients past medical, surgical and mental health history.

NameCard.TypeDescription & Constraints
..ObservationObservationMeasurements and simple assertions

...identifier1..1IdentifierUnique Id for this particular observation

....value1..1StringContains a DCE UUID
Example Value 18a80054-9bdb-4cb8-80d6-5992b300abf4

...status1..1Coderegistered | preliminary | final | amended +
Binding Codes providing the status of an observation. (http://hl7.org/fhir/ValueSet/observation-status)
Binding Strength Required
Fixed Value final

...code1..1CodeableConceptType of observation (code / type)
Binding Codes identifying names of simple observations. (http://fhir.nhs.net/ValueSet/cda-observation-type-1)
Binding Strength Example

....coding1..1CodingCode defined by a terminology system

.....system1..1UriIdentity of the terminology system
Fixed Value http://fhir.nhs.net/ValueSet/cda-observation-type-1

.....code1..1CodeSymbol in syntax defined by the system
Fixed Value SPMH

.....display1..1StringRepresentation defined by the system
Fixed Value Significant Past Medical History

...subject0..1Reference (cofe-patient-1)Who and/or what this is about

...encounter0..1Reference (Encounter)Healthcare event during which this observation is made

....reference1..1StringRelative, internal or absolute URL reference

....display0..1StringText alternative for the resource

...effective[x]1..1PeriodClinically relevant time/time-period for observation

...performer0..1Reference (cofe-practitioner-1 | cofe-device-1)Who is responsible for the observation

...value[x]1..1CodeableConceptA code from the chosen vocabulary to describe the significant past medical history of the patient
Binding SNOMED CT Code. (http://fhir.nhs.net/ValueSet/finding-snct-1)
Binding Strength Required

Path Name Binding Strength ValueSet
.Observation.status status Required http://hl7.org/fhir/ValueSet/observation-status
.Observation.category.coding.code code Required http://fhir.nhs.net/ValueSet/cda-observation-type-1
.Observation.code code Example http://fhir.nhs.net/ValueSet/cda-observation-type-1
.Observation.value[x] value[x] Required http://fhir.nhs.net/ValueSet/finding-snct-1

COFE-SPMH-Observation-1

Examples Description XML File JSON File
COFE-SPMH-Observation-1-Example-1 Example of significant past medical history